EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/78719
90 EW RESIDENTS February 2012 Cataract tips from the teachers Growing pains: When should an attending take over vs. letting a resident Maria M. Aaron, M.D. Associate professor of ophthalmology Emory University School of Medicine, Atlanta Sherleen Chen, M.D. Assistant professor of ophthalmology Harvard Medical School Director of Cataract and Comprehensive Ophthalmology Massachusetts Eye and Ear Infirmary S Roberto Pineda, M.D. Assistant professor of ophthalmology Harvard Medical School Director of Refractive Surgery Massachusetts Eye and Ear Infirmary J ust as in the sitcom "Growing Pains," it is sometimes very difficult to know when to step in to help or rescue the situation versus letting people learn and grow from their struggles. Similarly, in cataract surgical training, it can be difficult to find that balance of allowing the novice surgeon to struggle with surgical obstacles while simultaneously protecting the pa- tient's visual outcome. Of the many chal- lenges in teaching cataract surgery, this is one of the least clearly defined. In this col- umn, three of our expert cataract teachers share their philosophy on this difficult topic. Sherleen Chen, M.D., and Roberto Pineda, M.D. urgical education has sig- nificantly improved over the past 10 years. With the introduction of the out- comes project, advance- ments in surgical simulation, and emphasis on safety, training in mi- crosurgical procedures has pro- gressed. While complication rates for resident cataract surgeons are low and become lower with experi- ence, there is still an occasion for the attending surgeon to take over as primary surgeon.1 Naturally, in any patient en- counter, the primary focus must be on the patient; however, this does not necessarily preclude the resident from performing the procedure even when a complication has occurred. During phacoemulsification, it is often challenging to predict a poste- rior capsular tear prior to its occur- rence, but being able to recognize it and manage it are critical compo- nents in any surgical curriculum. In my experience, residency pro- grams differ in culture with regard to the issue of when the attending should take over the case. Typically, in hospitals where residents are the primary physicians (e.g., VA hospi- tals or county hospitals), the attend- ing physician is less likely to take over as the primary surgeon. I be- lieve that residents must learn how to manage complications and there- fore should remain the primary sur- geon in the majority of these cases, even if complications occur. How- ever, if the resident is physically, mentally, or emotionally not able to complete the surgery, I think it's rea- sonable for the attending to take over. When a resident has very little experience and lacks the dexterity to perform complex surgical maneu- vers, it is reasonable for the faculty member to perform these tasks and then return the case to the resident. On rare occasions, it is also reason- able for the attending surgeon to sit as the primary surgeon, just briefly to determine the status of the case (post capsular tear, zonular dialysis, etc.), and then let the resident man- age the complication when a plan of action is determined. Finally, the at- tending should always take over if a resident specifically asks for the at- tending to complete the surgery. When the resident is given the op- portunity to operate on a case where the patient is scheduled for the at- tending and the attending will be following the patient post-op, I think it is reasonable for the faculty member to take over the case much sooner. In my opinion, hands-on expe- rience with complication manage- ment is critical in surgical education. Therefore, it is essential that resi- dents remain primary surgeons, "find" vitreous, learn to manage complicated cases, disclose the error, and follow the patient post-op with the utmost care. Vikas Chopra, M.D. Associate residency program director Assistant professor of ophthalmology Doheny Eye Institute Keck School of Medicine University of Southern California, Los Angeles Teaching cataract surgery is different than coaching. No matter how poorly the players are performing during the game, the coach cannot actually join the game. The coach is limited to providing guidance and support from the sidelines. Cataract teachers, on the other hand, are more like co-pilots. They must ob- serve the resident surgeon operate, but jump in and take over at a criti- cal time that is not too soon but not too late. All of this is certainly easier said than done. During training, it is imperative for the residents to learn not only the proper surgical maneuvers to perform excellent cataract surgery, but also how to properly address unanticipated challenges and to manage complications. So how does one provide the resident an opportu- nity to learn, yet prevent the resi- dent from getting into real trouble that could lead to a poor surgical outcome? Both the attending physi- cian and the resident surgeon must understand their personal limita- tions and tolerances. Before each case, the teaching surgeon must categorize the resident surgeon in one of three categories— novice, intermediate, or expert—to be able to tackle that particular case. For example, a resident may be be- coming an expert in performing di- vide-and-conquer, but may be a novice in phaco chop; or a resident may be an expert in small incision phacoemulsification, but a novice in converting to extracapsular cataract extraction, if the need arises. A resi- dent may even conceivably be a novice in performing satisfactory phacoemulsification, but already be- coming experienced in managing ruptured posterior capsules from re- cent iatrogenic complicated cases. Finally, the attending surgeon should discuss the plan of action be- fore an upcoming case with the resi- dent surgeon to make sure their flight plans are aligned. During the case, the resident must be allowed to get into manage- able trouble and then be taught how to get out of trouble. For example, a radial tear during capsulorhexis can be managed by residents if they are familiar with the rhexis rescue tech- nique. A short incision that leads to iris prolapse through the incision presents an excellent opportunity to teach about iris management with viscoelastics, iris hooks, or possibly a Malyugin ring. Thus depending on the complexity in each situation, it may not be necessary to take over, but rather use it as an opportunity to teach from the co-pilot seat to ultimately correct the course. However, certain situations will demand quick and decisive action by the attending surgeon to assume the pilot seat and take over the case. For example, if a patient is quickly becoming uncooperative, prompt completion of the case is necessary. Another example is a serious sight- threatening complication such as an expulsive suprachoroidal hemor- rhage that needs immediate and decisive management. Therefore, the threshold for as- suming control needs to be person- alized and will likely vary based on several factors: an individual resi- dent's experience (or lack thereof), the nature of the intraoperative complication, the risk for poor surgi- cal outcome, and ultimately the abil- ity of the teaching surgeon to either co-pilot or assume pilot command to bring the situation to an optimal resolution.